Provider Demographics
NPI:1942580014
Name:JOHNSON, MATT DAVID (DDS)
Entity Type:Individual
Prefix:DR
First Name:MATT
Middle Name:DAVID
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24502 PACIFIC PARK DR
Mailing Address - Street 2:SUITE 106
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-3033
Mailing Address - Country:US
Mailing Address - Phone:949-831-1946
Mailing Address - Fax:949-643-2077
Practice Address - Street 1:24502 PACIFIC PARK DR
Practice Address - Street 2:SUITE 106
Practice Address - City:ALISO VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92656-3033
Practice Address - Country:US
Practice Address - Phone:949-831-1946
Practice Address - Fax:949-643-2077
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-22
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA606301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice